Akshat ethics in medicine

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PART ONE OF MODULE OF MEDICAL ETHICS LECTURE BY AKSHAT JAIN MD

PART ONE OF MODULE OF MEDICAL ETHICS LECTURE BY AKSHAT JAIN MD

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  • 1. AKSHAT JAIN MD New York Medical College Metropolitan Hospital Center NY, USA ETHICS IN MEDICINE
  • 2. What may this be ?
  • 3.
    • VIGNETTE – You are breaking the news of the lethal tumor that a 8 year old has been
    • diagnosed to have , and you tell the child and the parents that the prognosis does not look very
    • good in his case. The patient breaks down and begins to cry .What should you do?
  • 4.
    • EFFECTIVE COMMUNICATION
  • 5.
    • Poor communication between physicians and their patients may be a major contributing
    • factor in deciding why patients
    • Initiate a lawsuit , OR
    • Switch their doctors.
  • 6. • Basic concepts in communicating effectively.
    • • Listen actively -
    • Listening for content and meaning, responding to the feelings expressed
    • by children and their families, and carefully noting all verbal and nonverbal cues.
  • 7.
    • • Elicit the needs and concerns of children and families.
    • Eg. Finance , stress etc
    • • Acquire skills and practice in providing individual guidance.
    • Eg. – Dialects , Body Language.
  • 8.
    • TRICKS !
  • 9. Motivational interviewing
    • Enhances a patient’s intrinsic motivation to change by exploring their
    • perspective .
    • Rather than a set of techniques or a way of coercing treatment
    • adherence, MI explores how a person feels about the status quo and about change through EXPLORING the person’s values, interests, and concerns.
  • 10.
    • Express empathy
    • Ambivalence is normal
    • Roll with resistance -Resistance is not directly opposed.
    • New perspectives are invited but not imposed.
    • The client is a primary source in finding
    • answers and solutions.
    • Support self-efficacy A person’s belief in the possibility of change is
    • an important motivator.
  • 11. Reflective listening
    • Method both of resonating with a patient and of clarifying the meaning
    • of his or her statements. To demonstrate support of a patient’s efforts, a health care professional
    • may use affirmations.
  • 12.  
  • 13.
    • Everyone knows there is no "Gold Standard" for ethical behavior
  • 14. Defining “bad news”
    • Bad news is any information that changes a person's view of the future in a negative way. Physicians frequently must
    • break bad news to patients and their loved ones.
  • 15.
    • Withholding bad news from patients was commonly practiced until recently. But many recent studies have finally
    • found that most patients want to know the truth about their illness.
    • • When to deliver bad news?
    • “ It’s not what you say but when and how you say it.”
    • Do not force a patient to hear bad news if the patient does not want it at that moment, but do try to discuss it with him
    • or her as soon as possible.
  • 16.
    • • Who should deliver bad news?
    • It’s the duty of the physician treating the patient to tell about everything. Tell the patient everything, even if he or she
    • does not ask.
  • 17.
    • • How to deliver bad news ?
  • 18.
    • The ethics of health care in today’s era emphasize patient autonomy and full disclosure .
    • Honest revelation
    • of diagnoses, prognoses, and treatment options allows patients to make informed healthcare decisions that are
    • consistent with their goals and values.
  • 19. STEP WISE APPROACHES-
    • 3 models of ‘how to deliver bad news’ are described here:
    • --ABCDE
    • --ROBERT BUCKMAN’S 6 STEP
    • PROTOCOL
    • --THE SPIKES APPROACH
  • 20. Adapted from Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients that suffer. West J Med 1999;171:261
    • A dvance preparation--Arrange adequate time and privacy, confirm medical facts, review relevant clinical data, and emotionally prepare for the encounter.
    • B uilding a therapeutic relationship-- Identify patient preferences regarding the disclosure of bad news.
    • C ommunicating well--Determine the patient's EMOTIONAL STATE
    • D ealing with patient and family reaction-- Assess and respond to emotional, reactions and empathize with the patient.
    • E ncouraging/validating emotions- Offer realistic hope based on the , patient's goals and deal with your own needs.
  • 21. THE “B” - B uilding a therapeutic relationship-
    • "What have
    • you already been told about your illness?“ - level of technical sophistication
    • and the patient's emotional state.
    • Finding out how much the patient wants to
    • know.
  • 22. “C”- C ommunicating well-
    • Proceed at the patient's pace.
    • Avoid medical jargon or euphemisms, ( Eg -ANAND).
    • Allow for silence and tears, and answer questions.
    • Eg- " I'm going
    • to stop for a minute to see if you have
    • questions ".
  • 23. Barriers to effective disclosure
    • Physician fears:
    • • How will I, as the physician, cope with the patient's tears, anxiety, and fear?
    • • The fear of being blamed by the patient
    • • Fear of not knowing all of the answers sought by the patient,
    • of inflicting pain on the patient.
    • • Many physicians have had little or no formal training in how to break bad news,
    • • Many perceive a lack of time in which to present the news.
    • • Patients may have multiple physicians, making it unclear, who should break the bad news.
  • 24. o The setting & posture
    • • Allow enough uninterrupted time
    • • Arrange seating for comfortable, close communication.
    • • Avoid large desks and tables.
    • • If at all possible, both patient and physician should both be sitting.
    • • Ask the patient who else ought to be present, and let the patient decide--studies show that different patients
    • have widely varying views on what they would want.
  • 25. EYE CONTACT
    • • Make eye contact
    • • Defined touch
    • • Talk to the patient, not colleagues: patient is always the focus
  • 26. EMPATHY
    • Empathy is considered a mirroring or vicarious experience of another's emotions, whether they be sorrow or joy.
    • The patient relies on the physician to provide appropriate medical care and advice, as well as provide appropriate
    • psychosocial support
  • 27. How I do IT
    • "I wish I had better news" compared to "I'm sorry, I have bad news“
    • "I admire your courage," "I will be here for you," and "What gives you hope and strength?" as opposed to "It could
    • be worse,"
  • 28.
    • "We all die," "I understand how you feel," and "Nothing more can be done."
    • ”Does this news frighten you?“
    • ”What are you expecting to happen?”
    • ”How specific would you like me to be?”
    • ”What are your fears about what might happen?”
  • 29.
    • ”I wish the news were different.”
    • ”I’ll try to help you.”
    • ”I’ll help you tell your children.”
  • 30.
    • VIGENNETE –
    • The crying mother of a 6 y/o male child dying from a terminal illness ,requests you to “not” tell the boy about the
    • fact that he will die soon , The parents have decided in unison not to break the news ? How would you approach to
    • this problem?
  • 31. The tricky situation has to be handled very carefully.
    • -“Ask the family why they don't want to tell the patient?” - This can uncover relational issues and dysfunctional
    • family dynamics. Legally, of course, you are obligated to tell the patient; however, you may negotiate.
    • - Assess the patient for inappropriate coping skills, such as suicidal or homicidal ideation .
    • People will respond differently .In some cases, people may simply have
    • to leave the office. Emotional outbursts may make you very uncomfortable.
    • Try to give the patient and family time—and privacy—to react.
    • -Patient’s degree of capacity is a deciding factor in ascertaining the degree of self-determination he or she might
    • exercise in decision-making. Thus, it is incumbent on the physician to determine capacity, up to and including
    • mature minor
  • 32. TEACHING AIDS
    • • Standardized patients and simulated opportunities
    • • Didactic sessions
    • • GOOGLE
    • • Exposure to real-life experiences.